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BackgroundClinical characteristics, risks, and outcomes in solid organ transplant (SOT) recipients with zygomycosis in the era of modern immunosuppressive and newer antifungal agent use have not been defined MethodsIn a matched case-controlled study, SOT recipients with zygomycosis were prospectively studied. The primary outcome measure was success (complete or partial response) at 90 days ResultsRenal failure (odds ratio [OR], 3.17; P=.010), diabetes mellitus (OR, 8.11; P<.001), and prior voriconazole and/or caspofungin use (OR, 4.41; P=.033) were associated with a higher risk of zygomycosis, whereas tacrolimus (OR, 0.23; P=.002) was associated with a lower risk of zygomycosis. Liver transplant recipients were more likely to have disseminated disease (OR, 5.48; P=.021) and developed zygomycosis earlier after transplantation than did other SOT recipients (median, 0.8 vs 5.7 months; P<.001). Overall the treatment success rate was 60%. Renal failure (OR, 11.3; P=.023) and disseminated disease (OR, 14.6; P=.027) were independently predictive of treatment failure, whereas surgical resection was associated with treatment success (OR, 33.3; P=.003). The success rate with liposomal amphotericin B was 4-fold higher even when controlling for the aforementioned variables ConclusionsThe risks identified for zygomycosis and for disseminated disease, including those that were previously unrecognized, have implications for further elucidating the biologic basis and for optimizing outcomes in SOT recipients with zygomycosis

Zygomycosis is increasingly reported as a cause of life-threatening fungal infections. A higher proportion of cases reported over the last decades have been in cancer patients, with or without hematopoietic stem cell transplantation (HSCT). The new anti-fungal agent voriconazole is a recently identified risk factor for developing zygomycosis. We reviewed the clinical characteristics and outcomes of a large cohort of cancer patients who developed zygomycosis after exposure to voriconazole. Health care professionals at 13 large cancer centers provided clinical information on cancer patients with zygomycosis and prior exposure to voriconazole. Criteria for inclusion were 5 days or more of voriconazole use and diagnostic confirmation with tissue or histology. Fifty-eight cases were identified among patients with hematologic malignancies, 62% including patients who underwent a HSCT procedure. Fifty-six patients received voriconazole for primary or secondary prophylaxis against fungal infection. In addition to prior exposure to voriconazole, patients also had several of the previously established risk factors for zygomycosis. Amphotericin B was the most commonly prescribed anti-fungal therapy. Overall mortality was 73%. We conclude that zygomycosis after exposure to voriconazole is a recently described entity that is frequently fatal, despite treatment with currently available anti-fungal agents and surgery.

To the Editor: The Food and Drug Administration (FDA) approved voriconazole for the treatment of invasive aspergillosis partly on the basis of data published in a report in the Journal, 1 which showed an improved clinical response and improved survival with voriconazole treatment as compared with a strategy of initial treatment with amphotericin B deoxycholate. In patients with neutropenia and persistent fever, the use of voriconazole as empirical therapy failed to fulfill criteria for noninferiority as compared with liposomal amphotericin B, 2 and the results of that trial generated substantial discussion after the FDA declined approval of the drug for that indication. . . .

The number of reported cases of zygomycosis in patients with diabetes mellitus in developed countries has decreased since the 1990s, despite the rapid increase in the prevalence of diabetic patients in the Western world. Although prospective population-based studies need to better document this phenomenon, which may have a complex explanation, here I propose the hypothesis that widespread use of statins in patients with diabetes underlies such a trend. Statins have been shown to direct inhibitory activity against a range of Zygomycetes molds, both in vitro and in vivo.

A 44-year-old man with hepatitis B virus (HBV)-related cirrhosis underwent living donor liver transplantation at our institute. Induction of immunosuppression was achieved with basiliximab, due to deranged renal function, and maintained with prednisolone, tacrolimus and mycophenolate mofetil. The intraoperative and immediate postoperative periods were fairly uneventful. A duplex scan, taken during the third week post-transplantation due to sudden rise in liver enzymes, revealed multifocal hypoechoic lesions in the graft liver with normal Doppler parameters. Multidetecor computed tomography (MDCT) showed multiple hypodense vessel-sparing lesions in the graft liver. Cultures from the aspirate grew filamentous fungi identified as Basidiobolus ranarum species. Despite multiple broad spectrum antifungal infusions including liposomal amphotericin, itraconazole, caspofungin and posaconazole, serial sonography showed the hepatic lesions increasing in size, and involving segments V, VI and VII. The patient developed severe liver dysfunction ultimately progressing to sepsis, multiorgan dysfunction and death.

Zygomycosis is an opportunistic fungal infection that affects the central nervous system (CNS). In this report, we present three cases of zygomycosis with CNS involvement. In two patients zygomycosis developed after neurosurgery, and in the third patient zygomycosis developed after bone marrow transplantation for leukemia. All patients developed persistent fever and neurological deficits. They presented with progressive cerebral infarction accompanied by hemorrhage. Intraoperative findings and histopathological examinations revealed that zygomycotic hyphae caused mycotic aneurysm, vasculitis, and venous occlusion.

Basidiobolus species are filamentous fungi belonging to the order Entomophthorales. Unlike other zygomycetes, Basidiobolus species have been mainly associated with a tropical form of subcutaneous zygomycosis in otherwise healthy individuals. Visceral disease caused by this pathogen is rare, but cases of gastrointestinal infection with Basidiobolus ranarum have been reported worldwide. In many of these reports, the inflammatory disease of the colon has been confused with Crohn's disease. We report the third case of B. ranarum gastrointestinal infection in the United States, which was initially treated as inflammatory bowel disease.